Volunteer Services Application

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7600 SW 8th St, Miami, FL 33144

Phone: (305) 261-2525

Fax: (305) 261-5232

First Name: *

Last Name: *

Date of Birth: *

YYYY

Cell Phone #: *

Email: *

Address: *

(Street, City, State, Zip Code)

Emergency Contact Person: *

(Name & Phone Number)

Personal Physician: *

(Name & Phone Number)

Any Medications: *

What school do you go to?
*

Date of Application: *

YYYY

Date Available to Start:

YYYY

Days/Times Available to Volunteer:

Special Skills, Hobbies, Interests:

Experience with elderly or frail adults:

Name of 2 personal references that have known you for at least one year:

(Names & Phone Numbers)

Areas of Interest: (Check all that apply)

Reading to residents

Letter Writing

Clerical

Needlework

Bowling / Basketball

Discussions

Walks

Religious Services

Arts & Crafts

Nail Polish

Exercise

Cards / Checkers

Distributing Mail

Bingo

Gardening

Baking

Other:

Required

Have you ever been convicted of a felony or a misdemeanor?

Yes

If yes, please explain:

Submit

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